Healthcare Provider Details

I. General information

NPI: 1841612397
Provider Name (Legal Business Name): JASON COBB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 BLUE HERON COVE DR
FLEMING ISLAND FL
32003-4929
US

IV. Provider business mailing address

2117 BLUE HERON COVE DR
FLEMING ISLAND FL
32003-4929
US

V. Phone/Fax

Practice location:
  • Phone: 904-318-1335
  • Fax:
Mailing address:
  • Phone: 904-318-1335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 9276019
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: